LOUISVILLE, KY – REGIS WOODS

Based on observation, interview, record review, and facility policy, it was determined the facility failed to ensure residents with individualized care needs related to Dementia maintained the highest practicable physical, mental, and psychosocial well-being for one (1) of eighty-seven (87) sampled residents (Resident #31). Observations revealed staff, pulled the door to the door frame, expanded the privacy curtain in a manner which blocked the visual observation of the resident and activity from the hallway. The resident remained in bed in a room without audible stimulation. The resident yelled out for help and screamed with staff in the area, without response. In addition, the facility failed to initiate a care plan for the resident’s [DIAGNOSES REDACTED].

Observations on NF #2 Unit, on 09/15/2020 at 9:52 AM to 10:15 AM, revealed staff had the resident’s door pulled to the door frame and the room was dark. The resident yelled out Help, help, help, Licensed Practical Nurse (LPN) #6 sat at the nurse’s station and an aide walked past the door without addressing the resident’s call for help. Continued observations revealed the resident continued to yell out to let (him/her) go home, followed by hey and help repeatedly till 10:25 AM. Further observations at 2:50 PM, revealed the resident’s door was open with the room divider curtain fully expanded, which blocked the visual observation of the resident from the hallway and the resident faced the wall in bed. The resident continued to yell, help, let me go home, and hey repeatedly as CNAs #4 and #5 passed the room and continued down the hall and clinical staff sat at the unit desk. The resident’s room remained dark and without music or the television activated. At3:12 PM staff entered the room, and the resident answered yes when asked if he/she was okay.

Continued observations on 09/16/2020 at 9:45 AM, revealed Resident #31 remained in bed, curtain expanded, the room without light, and staff had not initiated music or television. During interview with Resident #31, he/she described his/her room as cold. The resident started to yell when the observer left the room.

Further observations at 3:10 PM, revealed the resident yelled out hey, help me, or just screamed out in the room while in bed with the curtain fully open without active stimulation of a radio or television. Two (2) aides, and 3 nurses stood at the unit station while the resident continued to yell out.

Further observation, on 09/17/2020 at 1:48 PM, revealed at the end of the NF #2 Unit hallway a resident could be heard yelling help. Further observation while walking toward the nurses’ station revealed the yelling came from Resident #31’s room. Staff had positioned the curtain two thirds of the way opened, the room remained dark without stimulation or activity for the resident. Observation revealed LPN #13 and LPN #30 continued to work at the nurses’ station while the resident continued to yell for help.

Further observation, on 09/18/2020 at 9:50 AM, revealed Resident #31’s divider curtain was fully expanded, which obstructed the view of the resident. The resident could be heard yelling help me, help me. Staff on the NF #2 Unit passed the resident’s door while the resident yelled for help until the NF #2 Unit Manager went into the resident’s room at 10:01 AM. Observation revealed Resident #31’s blanket was placed at the end of the bed, a hospital gown was up under both arm pits, the fall mat pushed into the middle of the room, no sensory stimulation of music or TV, and the room temperature was cold. The UM talked with the resident about lunch, getting up in the wheelchair, and the resident declined. The UM repositioned the gown, replaced the blanket, inquired if the blanket warmed the resident and the resident replied No. The UM then left the room.

Interview with CNA #4, on 09/25/2020 at 9:57 AM, revealed she could not respond to residents with dementia on the normal unit because she did not have time with all of her other responsibilities. She stated there was minimal staff to address constant yelling.